2012 CPLCs - Complete registration package

2012 CANADIAN
POOL LIFESAVING
CHAMPIONSHIPS
JUNE 1 - 2 - 3
KINSMEN SPORT CENTRE - 9100 WALTERDALE HILL
Tel: 780 415 1755 | Fax: 780 427 9334
11759 Groat Road | Edmonton, AB | T5M 3K6 | Canada
www.lifesaving.org
2012 CANADIAN POOL LIFESAVING CHAMPIONSHIPS CHAMPIONNATS CANADIENS DE SAUVETAGE EN PISCINE 2012 Registration Package
DATE
June 1–3, 2012
HOST
Lifesaving Society Alberta and Northwest Territories Branch
LOCATION
Kinsmen Sports Centre, Edmonton, Alberta
SANCTIONING
The 2012 Canadian Pool Lifesaving Championships has been sanctioned by the International Life
Saving Federation (ILS) and the Royal Life Saving Society Canada (RLSSC) and as such, any World
Records that may be broken will be recorded and submitted to ILS for processing. Rules governing
this championships will include those from the ILS Competition Manual (2011 edition) and Canadian
Competition Manual (2010 Edition).
FORMAT
Lifesaving Society “SANCTIONED EVENT WARM-UP PROCEDURES” will be in effect through the
championships. All Masters events will be swam as time finals in the morning. Finals will be
conducted in the 16-19 years and Open Division according to the Canadian Competition Manual.
EVENTS
100m Tow with Fins
100m Rescue Medley
50m Manikin Carry
100m Carry with Fins
POOL SPECS
The swimming pool at the Kinsmen Sports Centre is 2.2m deep for the entire length of the pool.
There are eight lanes with two outside gutter lanes of 2.5m on either side of the pool. There is a
minor slope discrepancy from Lane 1 to Lane 10 to accommodate drainage. The pool edges are
rounded meaning that manikins will not be flush with the wall.
EQUIPMENT
The host will supply Aquam Rescue Tubes, DLRG Manikins, custom obstacles and Throw Lines from
Canada Cordage for the use of competitors during competition. All competitors are required to supply
their own fins.
100m /200m Obstacle Swim 4 x 50m Medley Relay
100m /200m Super Lifesaver 4 x 25m Manikin Relay
Line Throw
4 x 50m Obstacle Relay
All equipment will comply with the ILS specifications as specified in the ILS Competition Manual
section 10.0
AWARDS
Awards will be issued in accordance with 2010 Canadian Competition Manual
ENTRY DEADLINE
Registration and complete entries must be received by Friday, May 18, 2012. Registration and
entries are considered to be complete when all of the following have been completed in full and
received by [email protected]

Registration Form (including male and female event entry forms)

Payment in full
LIFESAVING SOCIETY | 2012 CANADIAN POOL LIFESAVING CHAMPIONSHIP REGISTRATION FORM 2
2012 CANADIAN POOL LIFESAVING CHAMPIONSHIPS CHAMPIONNATS CANADIENS DE SAUVETAGE EN PISCINE 2012 
Waiver and Release form (originals may be provided at registration)

Hold a current Lifesaving Society Bronze Medallion or higher

Be a minimum of 16 years of age at of the first day of the Championships

Be a Registered Athlete (download form at www.lifesavingsport.ca)
ENTRY FEES
Competitor Fee
$80.00 per athlete
Late Fee (after May 18, 2012)
APPEALS
$100.00 per athlete
The Competition Appeals Committee will deal with all the protests referred to it by the Referee. The appeals
process is detailed in the current ILS Competition Manual. Appeals forms can be obtained from the
appointed Competitor Liaison.
The Competition Appeals Committee shall consider the protest or appeal and make a decision. It may
uphold or dismiss a protest or appeal. The cost of lodging an appeal is $100.00 including GST. If an appeal
is upheld the fee shall be returned.
The decision of the competition appeals committee is final and there is no right of appeal against that
decision.
DRUG POLICY Royal Life Saving Society Canada supports the Canadian Government, the Canadian Sports Commission,
the Canadian Olympic Committee, and the World Anti-Doping Authority (WADA) in their efforts to eradicate
the use of drugs in sport. These policies will be adhered to for this event.
Please also be aware that random drug testing could take place during the 2012 Canadian Pool Lifesaving
Championships.
ACCOMMODATION
AND OPTIONS
The Athlete Village will be hosted by Grant MacEwan University located in the heart of downtown
Edmonton. The University will be the site of Registration and Check In, Welcome Reception and
Closing Ceremony and reception as well as the athletes, officials and family accommodations. The
residence is located at 11050 - 104th Avenue, approximately three km north of the Kinsmen Sports
Centre. Transportation is also available for a minimal fee. Amenities within walking distance include
Save-On-Foods, Safeway, Hudson’s Canadian Tap House, Future Shop and all major banks.
Bachelor Suite
Hotel Rooms (Queen)
2 Bedroom Suite
4 Bedroom Suite
$65.00/night
$72.40/night
$80.00/night
$160.00/night
Please see accommodations booking information for further details or visit
www.macewanresidence.ca for a virtual tour.
LIFESAVING SOCIETY | 2012 CANADIAN POOL LIFESAVING CHAMPIONSHIP REGISTRATION FORM 3
2012 CANADIAN POOL LIFESAVING CHAMPIONSHIPS CHAMPIONNATS CANADIENS DE SAUVETAGE EN PISCINE 2012 RECEPTIONS
The Society will be hosting a Welcome Reception on Friday evening for all registered athletes,
officials, and volunteers. A Closing Ceremony and reception will also be hosted on Sunday evening
for all registered athletes, officials, and volunteers. Lifesaving Society Sport Awards and Overall
Championships awards in accordance will the 2010 Canadian Competition Manual will be presented
at this time. Both receptions are casual dress.
REGISTRATION
Please complete the appropriate forms along with payment in full:
PAYMENT

Championships Registration Form (including payment)

Event Entry Form

Waiver and Release Form

Registered Athletes Form
Cheques should be made payable to the Lifesaving Society. We also accept payment by invoice
(PO) Money Order, VISA, and MasterCard.
Lifesaving Society
Attention: 2012 Canadian Pool Lifesaving Championships
11759 Groat Road,
Edmonton, Alberta T5M 3K6
Email: [email protected]
Phone: 780-415-1755 Fax: 780-427-9334
ACCOMODATION
Athlete Village: Grant MacEwan University

Grant MacEwan Reservation Form
LIFESAVING SOCIETY | 2012 CANADIAN POOL LIFESAVING CHAMPIONSHIP REGISTRATION FORM 4
2012 CANADIAN POOL LIFESAVING CHAMPIONSHIPS CHAMPIONNATS CANADIENS DE SAUVETAGE EN PISCINE 2012 Friday June 1, 2012
12:00 p.m. – 5:00 p.m.
4:00 p.m. – 5:00 p.m.
8:00 p.m.
Saturday, June 2, 2012
Check-In
Key Officials Meeting
Welcome Reception
Paul Byrne Hall Grant MacEwan University
Paul Byrne Hall Grant MacEwan University
Paul Byrne Hall Grant MacEwan University
7:00 a.m. – 7:45 a.m.
7:00 a.m. – 7:30 a.m.
7:30 a.m. – 8:00 a.m.
8:00 a.m.
8:15 a.m.
8:30 a.m. – 12:30 p.m.
Warm –Up
Kinsmen Sports Centre
Coaches Meeting
Officials Meeting
Marshalling Session 1
Opening Ceremonies
Start of Session 1 Preliminaries
100m Rescue Medley
100m Carry w Fins
Line Throw
100M/ 200m Obstacles
4x 50m Obstacles Relay
BREAK
Warm –Up
Kinsmen Sports Centre
3:00 p.m. – 3:45 p.m.
3:00 p.m. – 3:30 p.m.
3:30 p.m.
4:00 p.m.
4:30 p.m. – 6:30 p.m.
Sunday, June 3, 2012
7:00 a.m. – 7:45 a.m.
7:00 a.m. – 7:30 a.m.
7:30 a.m. – 8:00 a.m.
8:00 a.m.
8:30 a.m. – 12:30 p.m.
3:00 p.m. – 3:45 p.m.
3:00 p.m. – 3:30 a.m.
3:30 p.m.
4:00 p.m.
4:30 p.m. – 6:30 p.m.
8:00 p.m.
Coaches Meeting
Officials Meeting
Marshalling Session 2 Finals
Start of Session 2
100m Rescue Medley
100m Carry w Fins
100m Rescue Medley Awards
Line Throw
100m Carry w Fins Awards
200m Obstacles
Line Throw Awards
4x 50m Obstacles Relay
200m Obstacles Awards
Warm –Up
Kinsmen Sports Centre
Coaches Meeting
Officials Meeting
Marshalling Session 3
Start of Session 3 Preliminaries
100M/ 200m Super Lifesaver
50m Manikin Carry
100m Tow w Fins
4x 25m Manikin Relay
4x 50m Medley Relay
BREAK
Warm –Up
Coaches Meeting
Officials Meeting
Marshalling Session 4
Start of Session 4 Finals
200m Super Lifesaver
50m Manikin Carry
100m Tow w Fins
4x 25m Manikin Relay
4x 50m Medley Relay
Closing Reception
Atrium, Grant MacEwan University
LIFESAVING SOCIETY | 2012 CANADIAN POOL LIFESAVING CHAMPIONSHIP REGISTRATION FORM 5
2012 CANADIAN POOL LIFESAVING CHAMPIONSHIPS CHAMPIONNATS CANADIENS DE SAUVETAGE EN PISCINE 2012 Program of Events
--
1

--
1
1

1

--
1

4x 50m Medley Relay

4x50m Obstacles Relay
1
4x 25m Manikin Relay

Lifesaving Penthalon
1
Line Throw
200m Super Lifesaver
100m Carry w Fins
100m Super Lifesaver
100m Tow w Fins
1
50m Manikin Carry
--
Team Events
Masters (30-34 yrs)
100m Rescue Medley
Open (16 yrs & Over)
200m Obstacles
16-19 yrs
100m Obstacles
Age Categories
Individual Events
For the 2012 Canadian Pool Lifesaving Championships, the following events shall be conducted in both male and female categories:
1



1




2
2
2

--





--
--

--





--
--

2
2
2
Masters (40-44 yrs)

--





--
--

2
2
2
Masters (45-49 yrs)

--





--
--

2
2
2
Masters (50-54 yrs)

--





--
--

2
2
2
Masters (55-59 yrs)

--





--
--

2
2
2
Masters (60-64 yrs)

--





--
--

2
2
2
Masters (65 & Over)

--





--
--

2
2
2
Masters (35-39 yrs)
1
2
The Lifesaving Pentathlon is comprised of the following five (5) events
Masters team events are conducted as total age events in the following age categories; 120 years +, 140 years +, 170 years +, and 200 years +
LIFESAVING SOCIETY | 2012 CANADIAN POOL LIFESAVING CHAMPIONSHIP REGISTRATION FORM 6
2012 CANADIAN POOL LIFESAVING CHAMPIONSHIPS CHAMPIONNATS CANADIENS DE SAUVETAGE EN PISCINE 2012 Championships Event Schedule
SESSION 1 SATURDAY JUNE 2, 2012 PRELIM WARM UP 07:00 AM START 08:30 AM 16‐19 100m Rescue Medley 16‐19 OPEN 100m Rescue Medley OPEN 16‐19 100m Carry w Fins 16‐19 OPEN 100m Carry w Fins OPEN 16‐19 200m Obstacles 16‐19 OPEN 200m Obstacles OPEN MASTERS 100m Obstacles MASTERS 16‐19 Line Throw 16‐19 OPEN Line Throw OPEN 16‐19 4x 50m Obstacles Relay 16‐19 OPEN 4x 50m Obstacles Relay OPEN SESSION 2 SATURDAY JUNE 2, 2012 FINALS WARM UP 03:00 PM START – 04:30 PM 16‐19 100m Rescue Medley 16‐19 OPEN 100m Rescue Medley OPEN 16‐19 100m Carry w Fins 16‐19 OPEN 100m Carry w Fins OPEN 16‐19 200m Obstacles 16‐19 OPEN 200m Obstacles OPEN 16‐19 Line Throw 16‐19 OPEN Line Throw OPEN 16‐19 4x 50m Obstacles Relay 16‐19 OPEN 4x 50m Obstacles Relay OPEN LIFESAVING SOCIETY | 2012 CANADIAN POOL LIFESAVING CHAMPIONSHIP REGISTRATION FORM 7
2012 CANADIAN POOL LIFESAVING CHAMPIONSHIPS CHAMPIONNATS CANADIENS DE SAUVETAGE EN PISCINE 2012 Championships Event Schedule (continued)
SESSION 3 SUNDAY JUNE 3, 2012 PRELIM WARM UP 07:00 AM START 08:30 AM 16‐19 200m Super Lifesaver 16‐19 OPEN 200m Super Lifesaver OPEN MASTERS 100m Super Lifesaver MASTERS 16‐19 50m Manikin Carry 16‐19 OPEN 50m Manikin Carry OPEN 16‐19 100m Tow w Fins 16‐19 OPEN 100m Tow w Fins OPEN 16‐19 4x 25m Manikin Relay 16‐19 OPEN 4x 50m Medley Relay OPEN 16‐19 4x 25m Manikin Relay 16‐19 OPEN 4x 50m Medley Relay OPEN SESSION 4 SUNDAY JUNE 3, 2012 FINALS WARM UP 03:00 PM START 04:30 PM 16‐19 200m Super Lifesaver 16‐19 OPEN 200m Super Lifesaver OPEN 16‐19 50m Manikin Carry 16‐19 OPEN 50m Manikin Carry OPEN 16‐19 100m Tow w Fins 16‐19 OPEN 100m Tow w Fins OPEN 16‐19 4x 25m Manikin Relay 16‐19 OPEN 4x 25m Manikin Relay OPEN 16‐19 4x 50m Medley Relay 16‐19 OPEN 4x 50m Medley Relay OPEN LIFESAVING SOCIETY | 2012 CANADIAN POOL LIFESAVING CHAMPIONSHIP REGISTRATION FORM 8
2012 CANADIAN POOL LIFESAVING CHAMPIONSHIPS CHAMPIONNATS CANADIENS DE SAUVETAGE EN PISCINE 2012 Championship Registration Form
Contact information/Coordonnées pour rejoindre l’équipe
 Club or Affiliate/Nom du Club ou Affilié:
Name/ Nom:
Coach/Entraîneur or/ou Manager/Gérant
Phone/Téléphone:
 Unattached/ Non attacé:
Mailing Address/Adresse postale:
Fax/Télécopieur:
Email/Courriel:
City/Ville
Province
Postal Code/Code postal
Entries will be confirmed by Email/Votre inscription vous sera confirmée par courriel. Please print clearly Écrivez lisiblement s.v.p.
Registration Fees/Frais d’inscription
How many?
Combien?
Description
Price each/
Coût de l’unité
Competitor Fee
Frais de concurrent
Late Competitor Fee
L'Entrée d'événement
Line total/
Total de cette ligne
$80.00
$100.00
Total
$
Payment/Paiement
Payment method/
Mode de paiement
Credit card number/
Numéro de la carte de crédit
Credit card holder/Nom du
titulaire de la carte de crédit
Signature of credit card holder/
Signature du titulaire de la carte
Phone/Email (if different than
above)/Téléphone/courriel (s’il
est différent de celui ci-dessus)
 Cheque / Chèque
 Money Order / Mandat
LIFESAVING SOCIETY | 2012 CANADIAN POOL LIFESAVING CHAMPIONSHIP REGISTRATION FORM  VISA
 MasterCard
 Invoice
Expiry date/date d’expiration
9
2012 CANADIAN POOL LIFESAVING CHAMPIONSHIPS CHAMPIONNATS CANADIENS DE SAUVETAGE EN PISCINE 2012 2012 Canadian Pool Lifesaving Championships  Championnats canadiens de sauvetage en piscine 2012
Event Entry Form / Formulaire d’inscription pour les épreuves
Event entries must indicate personal best times for seeding purposes. Competitors for whom no times are submitted will be considered to have the slowest times. Competitors are allowed to enter each event only once.
L’inscription aux épreuves doit inclure les meilleurs temps à des fins de pondération. Les athlètes qui ne fournissent pas de temps se verront attribués les temps les plus bas. Les athlètes peuvent participer une seule fois à chaque épreuve.
Last name, First name
Nom de famille, prénom
Last name, First name
Nom de famille, prénom
Last name, First name
Nom de famille, prénom
Last name, First name
Nom de famille, prénom
Last name, First name
Nom de famille, prénom
Last name, First name
Nom de famille, prénom
3:10.70 1:20:00 3:10.70
59.70
20.00
4 x 25m Manikin Relay
Relais mannequin 4 x 25 m
4 x 50 m Medley Relay
Relais 4 nages 4 x 50 m

4 x 50 m Obstacle Relay
Relais obstacle 4 x 50 m
3:10.70 1:10.70
Line Throw
Lancer de la corde
100 m Rescue Medley
Sauvetage 4 nages sur 100 m
50 m Manikin Carry
Portage d’un mannequin sur 50 m
100m/ 200m Super Lifesaver
Sauveteur d’acier sur100m/ 200 m
BRO224
100 m Carry with Fins
Portage avec palmes sur 100 m
16-19
Indicate team /
Indiquez les sous équipes par numéro
Lifesaving Penthalon
Pentathlon en sauvetage
M
F
Phone/Téléphone:
100 m Tow with Fins
Remorquage avex palmes
sur 100 m
Brown, John
100m/200mObstacle Swim
Nage avec obstacles sur 100m
200 m
Gender / Sexe
Registered Athlete`s Numbe
Nombre athlète
Competitor Name/
Nom de l’athlète
16-19 OR OPEN OR Masters
Jeunes sauveteur OU les séniors
OU les maîtres
PLEASE PRINT CLEARLY. ÉCRIVEZ LISIBLEMENT S.V.P.
:
 Club or Affiliate / Le Club ou Affilie OR/OU  Unattached / Sans attaches
Coach/Entraîneur or/ou
Email / Courriel
Manager / Gérant
Note: Line Throw: indicate team and thrower. Lancer de la corde : indiquez les sous équipes par numéro et lanceur / lanceuse
3:10.70 2:19.23 3:10.70
M
F
M
F
M
F
M
F
M
F
M
F
LIFESAVING SOCIETY | 2012 CANADIAN POOL LIFESAVING CHAMPIONSHIP REGISTRATION FORM 10
2012 CANADIAN POOL LIFESAVING CHAMPIONSHIPS Waiver and Release Form
Please read carefully before signing
Each competitor must sign this form and the entry form to be eligible to compete. Participants 18 years and under must
have the form signed by their parent or guardian.
1. Conduct
I agree to abide by the rules, regulations, and code of conduct of the championship, and further to behave in a manner
consistent with good sportsmanship.
2. Voluntary Assumption of Risk
As a competitor in a lifeguard competition, I recognize that there are certain risks inherent in the activity as a result of factors
including but not limited to: stress, number of people, water temperature and conditions. I have prepared myself for the
competition and know of no factor or condition which should be disclosed to the organizers or which would make it unsafe for
me to compete. I voluntarily assume all risks, both physical and legal including but not restricted to loss or damage to
property, and personal injury including permanent disability or death.
3. Waiver of Liability
As a condition of entry and in consideration of my application as an individual or as part of a team being accepted, I hereby
waive my right to make any claim, whether for negligence or otherwise against the Lifesaving Society, the City of Edmonton,
Grant MacEwan University, the Kinsmen Sport Center, the owner or occupier, the sponsors, the organizing committee or any
of the servants, agents, affiliates, volunteers, judges, officials, or other persons involved in the organization of and the
running of the competition, events or sanctioned associated activities. I further agree to indemnify and hold harmless all of
the above, from any claim made on my behalf or as a result of injury to my person or property.
4. Model Release
I transfer to the Lifesaving Society all rights whatsoever which I have in photographs and/or videos that photographers may
have taken. I consent to the use of the photographs/videos and my name for all purposes whatsoever, including without
limitation, television, publications, and any trade or advertising purposes.
I have carefully read and understand the four conditions of entry and in consideration for being allowed to compete, I have
executed them voluntarily intending to be bound thereby and intending these conditions to be binding of my heirs, personal
representative and assigns.
Print Name
Signature
Date
Coach
Manager
Captain
#2
#3
#4
#5
#6
#7
#8
Photocopy this page if you need to included additonal athletes.
LIFESAVING SOCIETY | 2012 CANADIAN POOL LIFESAVING CHAMPIONSHIP REGISTRATION FORM 11
CHAMPIONNATS CANADIENS DE SAUVETAGE EN PISCINE 2012
Formulaire de dispense et d’exonération
Veuilles lire attentivement avant de le signer
Veuillez lire attentivement ce document avant de le signer. Les athlètes mineurs (moins que 18 ans) doivent compléter le
formulaire avec la signature d’un parent ou du tuteur.
1. Comportement
J’accepte de me conformer aux règlements et au code d’éthique du championnat et de me conduire d’une façon qui va en
concordance avec les idéaux d’un bon esprit sportif.
2. Consentement aux risques encourus
En tant qu’athlète participant à la compétition, je reconnais qu’il y a certains risques inhérents à celle-ci. Les risques sont
reliés aux facteurs suivants, mais ne se limitant pas à ceux-ci : le stress, le nombre de personnes, les conditions et la
température de l’eau. De plus, il n’y a aucun facteur ou condition que je devrais dévoiler aux organisateurs qui rendrait
dangereuse ma participation à cette compétition. J’accepte de mon plein gré tous les risques physiques autant que légaux
reliés à ma participation, incluant mais ne se limitant pas à : perte ou dommage à la propriété, blessure personnelle incluant
un handicap permanent ou la mort.
3. Exonération de responsabilité
Comme condition à mon inscription en tant qu’individu et membre d’une équipe, je renonce à tous mes droits d’intenter une
poursuite que ce soit pour négligence ou autre envers la Société de Sauvetage, la Ville d` Edmonton, l`Universite de Grant
MacEwan, le Center de Sport Kinsmen, les opérateurs, les propriétaires ou occupants de l’installation, les commanditaires,
le comité organisateur, les agents, les affiliés, les bénévoles, les juges et officiels ou tout autre personne impliquée dans
l’organisation ou la tenue de la compétition, des épreuves et des activités connexes. J’accepte de plus d’indemniser et de ne
pas tenir responsable toutes les personnes nommées ci-dessus, de toute réclamation faite en mon nom ou suite à une
blessure à ma personne ou ma propriété.
4. Dispense du participant
J’accorde à la Société de sauvetage tous les droits quels qu’ils soient pour ce qui est des photographies et/ou des vidéos qui
auront été pris lors de la compétition. Je consens à ce que les photographies et les vidéos et mon nom soient utilisés pour
n’importes quels médias, sans limite, soit la télévision, les revues et dans tout but d’échange ou de promotion.
J’ai lu attentivement et je comprends clairement les quatre conditions de mon inscription et de ma participation à cette
compétition. J’y consens de plein gré et j’ai l’intention que mes héritiers, mes représentants personnels et ayants droits les
respectent eux aussi.
Nom en lettres moulées
Signature
Date
Entraîneur
Manager
Captain
#2
#3
#4
#5
#6
#7
#8
Photocopiez ce formulaire si vous avez un plus grand nombre d’athlète
LIFESAVING SOCIETY | 2012 CANADIAN POOL LIFESAVING CHAMPIONSHIP REGISTRATION FORM 12
MacEwan Residence
11050 –104 Avenue
Edmonton, AB T5K 2Y9
780-633-8000
780-633-8910
Lifesaving Society
June 1 – 3, 2012
Reserve your accommodation by faxing, mailing or emailing this completed form to MacEwan Residence at:
Fax: 780-633-8910
Mail: MacEwan Residence 11050 104 Ave Edmonton, AB T5K 2Y9 E-Mail: [email protected]
Please indicate your arrival and departure dates
Please indicate if you are an
May 29  May 31 June 1  June 2  June 3  June 4  June 5 
Coach/Team Manager 
Officials/Volunteer 
Athlete 
Family 
Last Name: ____________________
First Name: _________________
Address: ______________________________
City: __________________________
Prov. ______________
Postal Code: ___________________________
Res. Telephone: _________________
Cell/Work Phone: ______________
E-Mail Address: ________________________
(E-Mail where confirmation to be sent)
Accommodations Request
_____
2 Bedroom Suite (Max. 4 people)
$80/night
# of guests _____
_____
Bachelor Suite (Max. 2 people)
$65/night
# of guests _____
_____
Hotel Room (Queen Double)
$72.40/night
# of guests _____
_____
4 Bedroom Suite (Max. 8 people)
$160/night
# of guests _____
(Limited Availability)
Rates are subject to 5% GST and 4% Alberta Tourism Levy.
Shuttle and Parking Services
_____
Shuttle Service
$15/day/person
# of guests requiring Shuttle Service _____
_____
Parking
$5/night/vehicle
# of guests requiring Parking Service _____
Rates are subject to 5% GST
Meal Options
____
Sat., June 2: 6:00 a.m. – 7:00 a.m. - Breakfast
$12.00/person
Menu: Pancakes (2), Sausage (2) Scrambled Eggs, Fruit Salad, Juice, Coffee and Tea
# of guests _____
_____ Sat., June 2: Pick up between 6:00 a.m. – 7:00 a.m. – Boxed Lunch $11.49/person
# of guests______
Includes: Assorted 8-inch sub sandwich, veggies and dip, pasta salad, piece of whole fruit, dessert square, can of juice.
______ Sun., June 3: 6:00 a.m. – 7:00 a.m. - Breakfast
$12.00/person
Menu: Breakfast Wraps, Sausage (2), Pan Fries, Fruit Salad, Juice, Coffee and Tea
# of guests _____
_____ Sun., June 3: Pick up between 6:00 a.m. – 7:00 a.m. – Boxed Lunch $11.49/person
# of guests______
Boxed Lunch Includes: Assorted 8-inch sub sandwich, veggies and dip, pasta salad, piece of whole fruit, dessert square, can of juice
_____ Monday, June 3: 7:00 a.m. – 8:00 a.m. - Breakfast
$12.00/person
# of guests______
Menu: French Toast, Ham, Scrambled Eggs, Fruit Salad, Juice, Coffee and Tea
All taxes and gratuity are included in the price.
If less than 25 guests participate in meal options, meals may be cancelled with prior notice given to guests.
Cancellation Policy
Cancellations and changes may be made to room reservations and shuttle service up to 48 hours prior to the scheduled arrival date. After this time, all charges for all nights’ accommodation
and shuttle service will be applied to the credit card on file. There will be no refunds or adjustments for cancellations, no shows, late arrivals or early departures.
Cancellations and changes may be made to food reservations up to 10 days prior to the scheduled arrival date. After this time, all charges for all meals will be applied to the credit card on
file. There will be no refunds or adjustments for cancellations, no shows, late arrivals or early departures.

Full payment for all nights’ accommodation, parking, shuttle and food services is due upon arrival

All bedrooms are equipped with double beds; linen & towels are changed every three (3) days. Suites are not equipped with dishes or cooking utensils
PLEASE NOTE:
PLEASE FILL OUT THE CREDIT CARD AUTHORIZATION FORM ON PAGE 2 OF THIS FORM.
NO RESERVATIONS WILL BE ACCEPTED WITHOUT THIS FORM COMPLETED.
MacEwan Residence
11050 –104 Avenue
Edmonton, AB T5K 2Y9
780-633-8000
780-633-8910
Grant MacEwan University
MacEwan Residence
Credit Card Authorization
1. Credit Card Information:
O Visa O MasterCard
_________________________________________
___________
Card Number
Expiry Date
_________________________________________________
Cardholder Name
________________________________________
Cardholder Signature
_________________________________________________
Cardholder Phone Number
_________________________________________
Cardholder Email
2. Payment Authorization Information & Terms
I understand that processing of payments for all nights accommodation and taxes for this booking will
occur 48 hours prior to the scheduled arrival date.
I authorize Grant MacEwan University to charge the credit card indicated in this document
under the agreed terms.
I understand that if the cardholder information is not my own, I must have this authorization signed
by the cardholder before submitting payment authorization.
I agree to notify MacEwan Residence of any changes in expiry date, account information, reservation
dates, cancellations or termination of the authorization for payments.
I have read, understand and agree to the terms of the MacEwan Residence 48 hour payment &
cancellation policies.
I understand that by signing and submitting this form, I have read and agree to the terms of this form.
Reservation Holder Signature: ___________________________ Date: __________
Cardholder/Payee Signature: _________________________ Date: ___________
Please print, complete and scan to [email protected] OR fax authorization form to 780-633-8910
Personal information requested on this form is collected and protected under the authority of the Alberta Freedom of Information
and Protection of Privacy Act. The information is used for the purposes of managing the accommodation arrangements.
MacEwan Residence Internal use only
Confirmation #_____________________
Entered by ______________________ Tent Room # _____________________
Confirmation sent __________________
By__________________________
Express check in Info sent __________
LIFESAVING SPORT – ATHLETE REGISTRATION FORM
First Name: ____________________________ Last Name: ___________________________
Address: ____________________________________________________________________
City: _______________________ Province: ________________ Postal Code: ____________
Home Telephone #: ____________________ Date of Birth (y-m-d): _________ Gender: _____
LSS ID#: ______________ Email: _______________________________________________
Club/Affiliate: ________________________________________________________________
(If you are currently a Registered Athlete, you are not required to submit the following
documents. Please provide your Registered Athlete Number: ____________________).
Athletes must submit and attach at least one copy of legible documents that confirm and support each
of (1) Canadian Citizenship (2) Date of Birth (3) Lifesaving Society Award (you must hold Bronze
Medallion or higher certification):
(1) Canadian Citizenship:
(2) Date of Birth:
(3) Lifesaving Award:
Birth Certificate
Birth Certificate
Lifesaving Society Cert. Card
or
or
Canadian Passport
Canadian Passport
or
or
Citizenship Card
Citizenship Card
DECLARATION: I hereby declare that the statements made in this application are true.
Applicant’s signature:
Date:
Signed at:
Year / Month / Day
City / Province
FOR OFFICE USE: DOCUMENTS RECEIVED
Canadian Citizenship
Birth Certificate
Copy attached:
Yes
No
Passport
Copy attached:
Yes
No
Birth Certificate
Copy attached:
Yes
No
Passport
Copy attached:
Yes
No
Lifesaving Society Certification Card
Copy attached:
Yes
No
Date of Birth
Lifesaving Award
Registered Athlete Number: _________________________
Please mail, fax or email to:
Lifesaving Society, 400 Consumers Road, Toronto, Ontario M2J 1P8
fax: 416-490-8766
Email: [email protected]